HEALTH

Efforts to combat Medicare fraud draw mixed signals from indies, PBMs

BY Jim Frederick

WASHINGTON The independent pharmacy and pharmacy benefit management industries both praised new efforts by Congress and the Obama administration to end the fraudulent and abusive billing practices that plague Medicare and Medicaid and cost U.S. taxpayers tens of billions of dollars. But their recommendations for combating the problem are as different as their approaches to the pharmaceutical market.

The Centers for Medicare & Medicaid Services proposed new regulations to help prevent what the agency said is $55 billion in annual improper payments to providers and health plans. In a related development, the House Energy and Commerce Subcommittee on Health is looking at ways to attack the problem, and held a hearing Thursday titled, “Cutting Fraud, Waste and Abuse in Medicare and Medicaid.”

The National Community Pharmacists Association weighed in with a statement to the House panel that accused the pharmacy benefit management industry of responsibility for much of the abuse, which the group attributed to a “past record of alleged systematic chicanery.”

In its statement, the independent pharmacy lobby reminded lawmakers of numerous allegations of fraud by major PBMs, as well as “misrepresentation to plans, patients and providers; improper therapeutic solutions; unjust enrichment through secret kickback schemes; and failure to meet ethical and safety standards.” The group urged Congress to pass legislation “to rein in the waste being generated by the business practices of pharmacy benefit managers under Medicare and Medicaid,” and to increase the transparency of PBM audit practices.

Not surprisingly, the response from the Pharmaceutical Care Management Association, the main PBM industry advocacy group, was markedly different. Responding to new proposed regulations from CMS to combat fraud and abuse, PCMA president and CEO Mark Merritt said the government’s focus should be on preventing abuse rather than on pursuing wrongdoers after the fact for fraudulent billing practices. “Pharmacy benefit managers agree that prevention, not ‘pay and chase,’ is the key to fighting fraud,” Merritt noted. “Unfortunately, some public policies undermine the fight against fraud by requiring payers to include pharmacies in their networks that have been banned from federal programs.”

Merritt also reiterated PCMA’s call for legislation to eliminate legislative “prompt-pay” requirements that force pharmacy benefit plans to quickly pay prescription claims, raising again a major source of friction between the PBM and retail pharmacy industries. Policies that require payers to “accelerate payments,” PCMA’s leader charged, leave “less time to detect and prevent fraudulent Medicare claims before payments are made.”

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Drug offerings expand under Merck Helps programs

BY Alaric DeArment

WHITEHOUSE STATION, N.J. Merck is expanding its patient assistance program, the drug maker said Wednesday.

Merck announced an expansion of the number of drugs it offers under its Merck Helps programs, including the Merck Patient Assistant program, the Merck Vaccine Patient Assistance program, the ACT program for cancer and hepatitis C drugs, and the SUPPORT program for HIV and AIDS drugs. The program provides medicines and vaccines free of charge to eligible patients, primarily the uninsured, who make up to 400% of the federal poverty level and can’t afford Merck drugs without assistance.

 

“Merck has historically recognized the critical need for people to have access to the prescription medicines and vaccines they require, even if they lose their insurance,” Merck EVP and chief medical officer Michael Rosenblatt said. “Our patient assistance programs now provide access to even more medicines for chronic conditions like asthma, diabetes and high blood pressure, allowing us to reach more people in need.”

 

 

Merck also said that its philanthropic arm, the Merck Company Foundation, made a grant to NeedyMeds, a nonprofit group that helps people who can’t afford medicines or healthcare costs by making information about assistance programs available. NeedyMeds plans to use the grant to translate its website into Spanish.

 

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Study: Independent pharmacies earn high customer satisfaction scores

BY Allison Cerra

ALEXANDRIA, Va. Independent pharmacies have garnered the highest customer satisfaction scores among its competitors, according to results of a J.D. Power and Associates study.

The J.D. Power and Associates 2010 national pharmacy study found that Good Neighbor Pharmacy, Health Mart and the Medicine Shoppe Pharmacy –– networks of independently owned, locally operated pharmacies –– rated at 869, 856 and 851, respectively, on a 1,000 point scale, while patients said they were dissatisfied with publicly traded pharmacy chains and some mail-order pharmacies.

The National Community Pharmacists Association praised the study results, stating that “independent community pharmacies rely on a business model of answering questions and offering advice to ensure medication adherence is maximized.”

“This survey should encourage all patients and health plan sponsors to give independent community pharmacies another look. We offer superlative customer service, and we’re competitive on price,” said Joseph Harmison, NCPA president and pharmacy owner. “It’s also a reminder that policies that deny patients access to independent pharmacies, such as by mandating the use of mail-order pharmacies, not only eliminate choice but also the vital face-to-face interaction with clinically trained pharmacists.”

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